Clinical observations and lessons learned in the treatment of patients with thoracoabdominal aortic aneurysms.

Thoracoabdominal aortic aneurysms can be repaired successfully with acceptable rates of morbidity and mortality. Twenty-three men and seven women (an average age of 67 years) underwent 23 elective and seven emergency operations. Pulmonary complications were the most common, but renal insufficiency and paraplegia were the most serious postoperative problems. The average time of suprarenal aortic occlusion was 47 minutes, but neither renal insufficiency nor paraplegia was directly related to suprarenal clamp time. Four deaths occurred after elective procedures, two from postoperative bleeding (one death from a technical error) and two deaths from multisystem organ failure. Four late deaths were caused by myocardial infarction. The remaining patients are alive at two to 79 months after infarction. DeBakey's technique (multiple sidearm grafts from the main aortic graft) was used in the first three procedures, and the graft inclusion technique of Crawford, in the remainder. The graft inclusion technique reduced operating time and loss of blood by 50 per cent and intraoperative fluid requirements by 33 per cent. Hypothermia was minimized by extraperitoneal, rather than intraperitoneal, abdominal aortic exposure, heated ventilation and warmed intravenous fluids. Selective renal cooling was performed by catheter perfusion of the renal arteries. Extreme care must be taken in making openings and attaching grafts to visceral arteries to avoid troublesome hemorrhage. In contrast with patients with infrarenal aneurysms, those with thoracoabdominal aneurysms require prolonged ventilatory support and have considerably higher fluid requirements. Precise surgical technique is mandatory.